or resources to have limited literacy skills. Those enrolled in Medicaid, therefore, may be more likely to encounter barriers to care related to health literacy. Box 6-2 discusses the differences across states in dealing with health literacy and related issues in contracts with managed care providers of health care to those enrolled in Medicaid.

Roles of Regulatory Agencies

There are two main private organizations in the United States for accreditation and review of health-care facilities and providers: the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA).

Joint Commission on Accreditation of Healthcare Organizations The private, nonprofit JCAHO is the oldest and largest health accreditation organization in the United States, providing accreditation to over 17,000 organizations including hospitals, health-care networks, home care agencies, and nursing homes. Its mission is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support improvement in health care organizations” (JCAHO, 2003). JCAHO approaches health literacy through its standards on patients’ rights and on patient and family education and responsibilities. These standards include assessing patient and family involvement in care and care decisions, the informed consent process, and hospital patient education tailored to patients’ assessed needs, abilities, learning preferences, and readiness to learn. Compliance with these standards is assessed through document review, staff interviews, and review of patient complaints. However, it is not clear how effective these standards are in improving organizational performance regarding health literacy issues, and significant changes in this process are planned for 2004.

National Committee for Quality Assurance NCQA is a private, not-for-profit organization dedicated to improving health-care quality, best known for its work in assessing and reporting on the quality of the nation’s managed care plans through their accreditation and performance programs. NCQA identifies health literacy as a critical step in ensuring patient participation in their health care. Testimony to the Committee from NCQA indicates that thus far it has been unable to create a valid and reliable measure that is feasible to apply at either the health plan or provider level. Such a measure is critical in trying to hold health-care providers and insurers accountable for both initial health literacy and improvement in health literacy (personal communication, L. Gregory Pawlson, M.D., M.P.H., NCQA, June 13, 2003). Regardless, there are a few provisions related to



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